Source: Harvard Business Review, January 31, 2019
By Humaira Ameer* & Sachin H. Jain*
What if there was a way to
significantly improve health outcomes, reduce hospital and nursing home
admissions, and save $105 billion in health
spending? There is one such compelling
opportunity: a greater systemic focus on medication adherence. When health care
professionals use the term “medication adherence,” what we’re really
referencing is whether or not patients take their medicines as prescribed.
Shockingly, about half the time, they don’t. And the consequences of
non-adherence are great.
One of the leading studies of
the topic found that “approximately 125,000 deaths per year in the United States are due to medication non-adherence.” No
wonder, then, the World Health Organization (WHO) has determined that “increasing the effectiveness of adherence
interventions may have a far greater impact on the health of the population
than any improvement in specific medical treatments.”
Medicare and Medicaid patients
with multiple chronic conditions who tend to take multiple medications account
for a disproportionate share of all health spending in America. Recognizing the
important opportunity to improve the care for such patients, CareMore Health, a division of Anthem, Inc.
that serves Medicare and Medicaid beneficiaries, launched a program. It was
designed to leverage the clinical expertise of pharmacists to identify the root
causes of non-adherence and hyper-personalize solutions to better support the
patients we serve.
Our discovery: The reasons
patients don’t take medicines vary significantly; consequently, to improve
adherence, you have to customize the solution for each individual. This is a
significant departure from past efforts to improve adherence, which have tried
to apply a single solution across a whole population.
We started our pilot program
by identifying about 250 non-adherent patients and then dividing them into two
groups: an “intervention” group and a “control” group. These were patients who
typically had multiple chronic diseases and many prescriptions — who were
not taking them because they either didn’t fill their prescriptions or
irregularly refilled them. We challenged pharmacists embedded within our
clinics to use “any reasonable means” to support patients in the intervention
group in improving their adherence.
The pharmacists conducted
educational meetings with patients — both in person and over the phone
— to understand why they weren’t taking their medications as prescribed
and designed personalized care plans to improve adherence. We started to see
some repeated patterns: patients’ stories that are emblematic of the challenges
patients face and the solutions that can help them.
About a third of patients told
us they were overwhelmed by the complexity of their medication regimens. One
patient we’ll call “Stanley” told us he was supposed to inject insulin up to
five times per day. Meanwhile, Stanley’s mealtime insulin was based off a
“sliding scale,” meaning he had to check his sugar level before each meal to
determine how many units he had to inject. Stanley is retired and babysits his
grandchildren after school every afternoon. He told us that he found it
difficult to carry his glucometer and mealtime insulin with him when he was out
of the house each day. Not surprisingly, Stanley used words like “stressed” and
“frustrated” to describe how he felt about his medication regimen.
Additionally, almost half of
the patients said they didn’t understand why they were prescribed
certain medications or what those medications were supposed to do. “Anna,”
another patient, told us she only injected insulin if she “felt” her sugar
levels were high. Not surprisingly, Anna’s blood sugar remained dangerously
hyperglycemic.
While some patients reported
that cost was a barrier to adherence, many more spoke frankly about their own
cognitive functioning. Many older patients told us they had trouble remembering
when or if they’d taken their medications. “Laura” stated that she had spilled
her pills on the counter one morning, couldn’t remember which pill went in
which bottle, and gave up on them all.
In total, we discovered that
each patient identified, on average, about two dominant obstacles to adherence
per patient. Our teams went to work with the express goal of removing those
obstacles. Stanley’s care team, for instance, adjusted his medication regimen
to make it less burdensome, putting him on a different formulation of insulin
that he injects just twice a day. Within two months of the change, his A1c
number, which indicates blood sugar levels, was lowered from 9.8% to 7.7%.
In many cases, clinical care
teams spend a lot of time simply educating patients about their medications. A
pharmacist explained to Anna the difference between maintenance and mealtime
insulins and how they work together to regulate blood sugar levels. He also
simplified her regimen by putting her on premixed insulin and an oral
medication that meant she only had to inject herself twice a day. To avoid any further
confusion, the CareMore pharmacist called Anna’s retail pharmacy to stop all
old insulin prescriptions. He performed a home visit and disposed of all of
Anna’s expired medications, created a new easy-to-read medication list for her
to follow, and consolidated her pills into a pillbox labeled to show her which
pills to take in the morning, afternoon, and evening. Anna’s blood sugar
control has also improved significantly.
Many of the solutions that
emerged were quite creative. In Tucson, Arizona, for example, a pharmacist
encountered a patient who didn’t open her door very often because it was too
hot outside. Consequently, when delivery services left her insulin on the front
porch, it would spoil in the 115-degree heat. So the pharmacist found a local,
independent pharmacy to deliver this patient’s insulin. That pharmacy schedules
deliveries with the patient and makes sure she puts her insulin inside the
refrigerator before the deliverer leaves.
As the pharmacists learned
more about the specific obstacles older patients face, they adjusted their
practices accordingly. For example, switching from bottles to pill boxes and
pill packs, in which medications are pre-sorted and packaged by dose, so
there’s never any guesswork about whether a patient has missed a dose. Also,
the packages are easy to open, which makes things easier for patients like
Frank, who’s 68, has arthritis in both hands that it made it difficult to open
his pill bottles — something he was embarrassed to disclose even to his
wife.
The success that this flurry
of innovation produced was frankly surprising. To validate our findings, we
partnered with a biostatistics team at the University of Southern California to
observe our experiment and corroborate the results. According to their report,
we improved medication adherence among the patients in our intervention group
by 46% compared to people in our control group, who received usual care from
their doctors and nurses but no special interventions from pharmacists.
The problem of non-adherence
is as old as our oldest medicines — and is grounded in the simplistic
belief that patients will always behave as we expect them to. Our early work in
this area suggest otherwise. Although there’s certainly more to learn, we’re
not waiting to implement what we call a “culture of adherence.” It starts with
humility in recognizing that patients may not always follow what their doctors
and nurses recommend and we need to continuously try to understand why.
While some common themes
emerged from our program, we found that the reasons any one patient does or
doesn’t take his or her medications is often exquisitely personal. Pharmacists
on clinical teams can be deployed to identify causes of non-adherence and
carefully tailor solutions. It is now standard practice for our care teams,
which include clinical pharmacists, to regularly examine medication adherence
data for each patient. We lead with the mantra that “medication adherence is
our problem, not the patient’s problem.”
As pharmacists and pharmacies
begin to play a bigger and bigger role in the delivery of health care, we
believe a mandate to drive an enhanced hyper-personalized focus on medication
adherence will unlock significant savings and, more importantly, improve the
quality of care.
The best medicines are only
effective if we ensure our patients take them.
*Humaira Ameer is manager of clinical pharmacy operations at CareMore Health System, a
division of Anthem, Inc.
* Sachin H. Jain, MD, is president and CEO of the CareMore Health System,
a division of Anthem, Inc. He is also a consulting professor of medicine at the
Stanford University School of Medicine. He previously was the chief medical
information and innovation officer at Merck. Follow him on Twitter at @sacjai.
